Presentation:
- Bulge at the surgery site
- Dragging pain (esp in obese, pregnant ladies)
- Relieved by abdominal binding
- Complications: obstruction or strangulation
- Don’t insist on feeling the size of defect (esp if non-reducible), why? very painful and it won’t change anything in the management in the clinic -> measure it in the OR
Patient-related factors:
- Age:Â old age is related to weak fascia -> improper healing
- Gender is controversial
- Poor glycemic control:
- Diabetes is not an independent risk factor of incisional hernia
- Most important pre-op prep to prevent surgical-site infections is strict glycemic control (which is measure by HgbA1C) (more important than antibiotics)
- Surgical site infection is the single most imp factor of developing incisional hernia!
- Collagen vascular diseases: Ehler-Danlos syndrome, Marfan syndrome, SLE, vasculitis
- Smoking -> causes degradation of collage and destroys good fascia
- AAA -where smoking affects the content of collage in a vessel wall- surgery through a midline laparotomy carries a higher risk of hernia
- Immunodeficiency: congenital, acquired, immunosuppressive therapy, steroid, chemo, radiation
- Malnutrition: can be general or specific (zinc or vitamin C deficiency), obesity (a form of malnutrition)
- Increased intra-abdominal pressure:Â due to;
- Obesity
- Pregnancy
- Ascites: hepatic (portal HTN), cardiac (right HF), renal (nephrotic), intestinal (protein-losing enteropathy), peritoneal dialysis, carcinomatosis
- Intra-abdominal tumors which attain large caner: ovarian, endometrial fibroids, desmoid tumors, GEST, lymphomas, cystic lesions of pancreas, mesenteric cyst
- Retroperitoneal tumors or sarcoma
- Chronic cough
- Constipation
- BPH causing chronic obstructive urinary symptoms
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Surgery related factors:
- Types of incisions
- Midline laparotomy is the worst when it comes to risk of incisional hernia but the best for exposure
- Same incision, different procedure:
- Midline laparotomy for splenectomy -> clean
- Midline laparotomy for gastrectomy -> clean-contaminated
- Midline laparotomy for colectomy in a prepped colon -> contaminated
- Midline laparotomy for colectomy in an un-prepped colon -> dirty
- Same incision, same procedure, elective vs emergency:
- Left hemicolectomy on emergency -> higher risk of herniation compared to elective left hemicolectomy
- Closure:
- No difference in the risk of hernia between interrupted vs continuous closure -> so for convenience, we always close w\ continuous
- What’s important is taking good fascia, good distance, no tension (which causes recurrence and strangulation of tissue)
- Type of suture:
- No difference between resorbable vs non-resorbable -> so use appropriately resorbable sutures (which gives enough time for fascia to heal and prevent hernia)
CASE: 2 patients, one w\ 10-cm defect, the other w\ 2-cm defect. Which one you’ll do first?  The smaller one -> risk of bowel entrapments, strangulation, and irreducibility
CASE: Child-Pugh C cirrhotic pt, bed bound, very little activity, w\ wide neck hernia. Would you repair it? No, b\c he is a poor surgical candidate and the hernia is not “bothering” him
Treatment:
- Surgical repair for active pts with symptoms
- Mesh vs no mesh?
- Primary hernia -> depends on the size:
- Big primary hernia -> mesh
- Small primary hernia -> no mesh
- Incisional hernia -> always use mesh!
- Mesh doesn’t increase the risk of infection, but makes infection easier to develop .. 🙂
- Always give pre-op abx if you’re contemplating putting a mesh
- Primary hernia -> depends on the size:
- Open vs laparoscopic?
- Small hernia (1-2 cm) -> open
- ≥ 3 cm hernia -> laparoscopic
- Giant hernia (> 15 cm, should be taken in the light of torso size, or > 50% of abdominal content outside) -> open
- Don’t advise pt to use abdominal banding if they are a surgical candidate, why?
- Pressure on the skin -> skin abrasions and infection -> high risk of surgical-site infection
- Disuse atrophy
- Mesh vs no mesh?
Lumbar herniaÂ
- Difficult to treat; no fascia + between two bony prominences -> no place to fixate mesh
Epigastric hernia:
- Anywhere in the midline (linea alba = extra-peritoneal fat -> no true sac, only breach in muscle fibers), from xiphoid to 2-cm above umbilicus, usually small and very painful
Download the PDF version: here
References:
- Dr Alabeidi’s lecture and clinical notes